Transcript Slide 1

Unsafe Abortion Mortality: New
Estimates and Trends, Health and Social
Consequences
Professor FE Okonofua
University of Benin, Nigeria
Presented at the International
Interdisciplinary Symposium on Reducing
Maternal Mortality in sub-Saharan Africa:
better understanding for better action
Dakar, Senegal – December 13-16, 2010
July 18, 2015
1
Background
 The WHO defines Unsafe Abortion as: “A procedure for
terminating an unintended pregnancy that is carried out
either by a person lacking the necessary skills or in an
environment that does not conform to minimal medical
standards, or both¨
 Despite increasing prevalence of contraception and the
existence of safe and effective methods of abortion,
millions of unsafe abortion continue to take place globally
each year resulting in increased risks of associated
morbidity and mortality
 The objective of this presentation is to provide the most
recent WHO estimates of unsafe abortion and to elucidate
the associated health and social consequences
July 18, 2015
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Methodology
 Review of the most recent WHO publications and
database on unsafe abortion and associated
mortality
 Review of other publications relating to trends in
abortion incidence and mortality
 Recent papers published by Shah and Ahman in
Reproductive Health Matters and Susheela Singh
in the Lancet
July 18, 2015
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Unsafe Abortion in 2008
 WHO estimates that 21.6 million unsafe abortions took
place worldwide in 2008, almost all in developing
countries
 The best indicators for measuring unsafe abortion are:
- Unsafe abortion rate: the number of
unsafe abortions per 1000 women aged 15-44 years
- Unsafe abortion Ratio: the number of unsafe
abortions per 100 live births
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Estimated Annual Incidence of Unsafe Abortion
per 1000 Women Aged 15-44 years, by UN Subregion, 2008
Unsafe Abortion
Ratio (per 100
live births)
(rounded)
Unsafe
Abortion Rate
(per 1000
women aged
15-44 years)
21,600,000
360,000
21,200,000
5,020,000
5,510,000
6,190,000
2,430,000
930,000
900,000
120,000
14
1
16
27
31
28
36
36
18
9
16
3
17
18
17
17
20
18
18
10
Number of
Unsafe
Abortions
World
More developed regions*
Less developed regions
Least developed countries
Sub-Saharan Africa
Africa
Eastern Africa
Middle Africa
Northern Africa
Southern Africa
5
Contd
Western Africa
1,810,000
28
16
Asia*
10,810,000
12
14
Eastern Asia*
°
°
°
South-Central Asia
6,850,000
17
17
South-eastern Asia
3,130,000
22
28
Western Asia
830,000
16
16
Europe
360,000
2
5
Eastern Europe
360,000
5
12
Northern Europe
°
°
°
Southern Europe
°
°
°
Western Europe
°
°
°
Latin America and the Caribbean
4,230,000
31
39
Caribbean
170,000
18
22
Central America
1,070,000
29
34
South America
2,990,000
32
43
Northern America
°
°
°
Oceania*
18,000
8
7
Australia/New Zealand
°
°
°
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Estimated Annual Number of Unsafe Abortions,
Rates and Ratios, By Geographical Regions, 2008
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Unsafe Abortion Rates Per 1000 Women of
Ages 15-44 For All Countries
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Estimated Number of Unsafe Abortion Globally and by Major
Regions, 2003 and 2008
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Unsafe Abortion Rates Per 1,000 women
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Consequences of Unsafe Abortion
 Despite being a simple procedure, one in four women
having an unsafe abortion face the risk of severe
complications
 Worldwide, unsafe abortion account for 13% of maternal
deaths, and 20% of overall burden of maternal death and
longer term disability as measured in Disability Adjusted
Life-Years (DALYs)
 Compared with developed countries the burden per 1000
unsafe abortions is more than six times as high in subSaharan Africa and four times as high in Asia
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Consequences of Unsafe Abortion
 Unsafe abortions accounted for 20,500 maternal
deaths in 2005
 Among the estimated 358,000 global maternal
deaths in 2008, 47,000 were due to complications
of unsafe abortion (nearly a doubling)
 Over half of these were in Africa, while 34%
occurred in the least developed countries
 MMR associated with abortion was 650 deaths
per 100,000 unsafe in 2003 , compared to 10 per
100,000 in developed countries
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36% The World’s Population Live Where
Abortion is Very Restricted
26%
Prohibited altogether
or only to save life
40%
Physical Health
Mental Health
Socioeconomic
10%
Without restriction
3%
21%
July 18, 2015
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Restricting Contraception and Legal Abortion In
Romania Resulted In Increased Maternal And Abortionrelated Deaths
Maternal and unsafe abortion deaths per 100,000 live births, by year, Romania
200
Maternal deaths
Abortion deaths
160
120
80
40
0
1960
1964
July
18, 20151968
1972
1976
1980
1984
1988
1992
1996
14
Distribution of Countries by Number of Deaths due to
Unsafe Abortion
Number
of
deaths
per
100 000
live
births
July 18, 2015
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Distribution of Countries By Number of
Deaths Due to Unsafe Abortion
Region and Sub-region
Number of maternal
deaths due to unsafe
abortion (rounded)
Deaths due to unsafe
abortion (as % of all
maternal deaths)
Deaths due to unsafe
abortion per 100,000
live births (rounded)
World
More developed
Less developed
Countries
Least developed
countries
Less developed regions,
excluding China
Africa
Eastern
Middle
Northern
Southern
Western
70 500
<60
70 400
13
4
13
55
.
60
24 000
10
85
70 400
13
70
38 400
14 800
6600
1200
500
15 300
14
17
11
11
9
13
115
130
130
25
40
140
July 18, 2015
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Estimates of Deaths due to Unsafe
Abortion in 2005 in three countries
Annual number of women treated
in hospital for induced abortion
complications
Annual hospitalization rate
for induced abortion
complications per 1000
women
Egypt
216 000
15.3
Nigeria
142 200
6.1
Uganda
85 000
16.4
July 18, 2015
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Health Consequences Are Often Severe
And Can Be Long-term
 Kenya: 28% of post-abortion patients
experienced severe complications
 Nigeria: among hospitalized patients, one in 3
had hemorrhage, one in four sepsis and about
1 in 10 had injury to other organs
 Abortion in the second trimester greatly
increases risk
 There are many long-term consequences
July 18, 2015
Additional Consequences
 Loss of productivity
 Increased economic burden and cost to the public
health system
 Social & cultural stigma
 Long term ill-health, including infertility
 Overall , some 24 million women are estimated to be
currently suffering from secondary infertility due to
unsafe abortion
July 18, 2015
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Contraception is Key to Prevention Of Unsafe
Abortion
 It is well documented that family planning
programs reduce abortion
 There can be a lag: the desire for small families
may increase faster than contraceptive use
 But contraception does not eliminate the need
for safe abortion, and there are several other
reasons why women result to abortion
 Governments and stakeholders must improve
access to contraceptive information and services
July 18, 2015
Prevention of Unsafe Abortion Includes
More than Contraception
 Access to safe and legal abortion is the most
fundamental means of prevention
 Also important are use of safer techniques
and training of providers in these techniques
 Manual vacuum aspiration is effective and
suitable for low resource settings
 Early medication abortion is a new and
recommended technique
July 18, 2015
Prompt And Appropriate Treatment Of
Complications Is Also Important
 WHO has issued guidelines for provision
of safe abortion care & treatment of
complications
 Post abortion contraceptive counseling
and services are essential
 Rapid transfer to tertiary care can be
lifesaving
July 18, 2015
The Public Health Imperative
 The rationale for making safe abortion
available is well established
 The public health record is clear and
incontrovertible: access to safe, legal
abortion improves health
 Cairo, 1994:”In circumstances where abortion
is not against the law, such abortion should
be safe.”
July 18, 2015
Dealing with Unsafe Abortion in Africa
The Maputo Plan of Action
 Enact policies and laws to reduce the incidence of unsafe
abortion
 Prepare and implement national POA to reduce the incidence of
unwanted pregnancies & unsafe abortion
 Provide safe abortion services to the fullest extent of the law
 Educate communities on available safe abortion services as
allowed by natural laws
 Train health providers in prevention and management of unsafe
abortion
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Mahmoud Fathalla Sums Up The Situation
Very Well
“Pregnancy-related deaths are often the
ultimate tragic outcome of the cumulative
denial of women’s human rights. Women
are not dying because of untreatable
diseases.
They are dying because
societies have yet to make the decision
that their lives are worth saving.”
Simply put, they die because they do not
count.
July 18, 2015
Some References:
 Shah H, Ahman E. Unsafe abortion: global and regional
incidence, trends, consequences and challenges. J Obstet
Gynecol Can 2008; 31: 1149-1158.
 Singh S. Hospital Admissions resulting from unsafe abortion:
estimates from 13 developing countries. Lancet 2006; 368:
1887-1892.
 Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua
FE, Shah IH. Unsafe abortion: A preventable pandemic. Lancet
2006 (Special Edition): 65-76.
 Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced
abortion: estimated rates and trends worldwide. Lancet 2007,
370, 1338-1345
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Acknowledgements
 Dr Alain Prual of UNFPA,
and
Dr Brooke Levandowski of Ipas, USA
For sharing some of the reading
materials with me.
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Thank you
Merci
July 18, 2015
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